Celiac Disease Presenting as Unexplained Infertility

Celiac Disease Presenting as Unexplained Infertility Title- Celiac disease presenting as unexplained infertility and pancytopenia- A Case Report Abstract – Celiac disease is an autoimmune disorder of the small intestine significant association with several extraintestinal features, such as reproductive disorders in women with undiagnosed celiac disease. Worldwide, CD prevalence is approximately 1%. Several studies suggest a higher prevalence of undiagnosed CD in patients with infertility. A 21 years old Indian woman who presented with history of primary amenorrhea, diminished secondary sexual character, asthenia, history of weight loss and chronic diarrhea. On admission her hemoglobin (Hgb) was 4.2 g/dL. Laboratory investigations confirmed a Immunoglobulin A (IgA) anti-tissue transglutaminase antibodies (IgA-tTG) was markedly elevated to more than 300 u/ml, colonoscopy was normal, Bone mass densitometry revealed osteopenia and hypercellular bone marrow on bone marrow biopsy. Celiac disease diagnosis was made multivitamins, mineral, intravenous iron replacement and gluten free diet replacement treatment was initiated. In order trilineage hematopoiesis, iron deficiency anemia, granulocytic hyperplasia and mild megakaryocytic hypoplasia. Both her platelet counts and white blood cell recovered uneventfully with continuing iron, calcium, vitmine D3 and folic acid supplementation. The possible mechanism for this phenomenon is discussed in this report. Introduction Celiac disease (CD) is a multifactorial chronic autoimmune systemic disease, triggered by gluten consumption in genetically predisposed individuals [1]. Classically the disease is manifested by symptoms of diarrhea, flatulence and malabsorption, however, it is also associated with variable systemic manifestations, including metabolic bone disease, diabetes, thyroid dysfunction and lympho-proliferative malignancies [2]. Worldwide, the prevalence of CD in the general population is approximately 1%; female: male ratio is 2 : 1 [3-7]. Several studies have confirmed the implications of celiac disease on the reproductive health of women. Celiac disease Development in cases of acute leukemia after allogeneic bone marrow transplantation (BMT) from Human leukocyte antigen identical siblings who suffered from celiac disease [11,12]. We report the first case of celiac disease presented as pancytopenia with unexplained infertility in woman Case report A 21 year old Indian woman presented with primary amenorrhea, diminished secondary sexual character, asthenia, history of weight loss and chronic diarrhea. On admission her hemoglobin (Hgb) was 4.2 g/dL (normal range: 11.0–15.1 gm/dL), red cell distribution width (RDW) was 39% (normal range: 11.3–15.5%) and mean corpuscular volume was 63.6 fL (normal range: 79–97 fL). Reticulocyte count was low at 9000/mm3(normal range: 25–100 Ãâ€" 103/mm3), total iron binding capacity of 486 ÃŽ ¼g/dL (normal range: 250–450 ÃŽ ¼g/DL), percentage saturation of 5 and a ferritin level of 3/mcL (normal range: 150 – 400 Ãâ€" 103/ÃŽ ¼L), white blood cell (WBC) count was 3.2 Ãâ€" 103/ÃŽ ¼L (normal range: 4–11 Ãâ€" 103/ÃŽ ¼L) with 4-6 segmented neutrophils. On the bone marrow core sections ring sideroblasts was not found. Bone marrow iron store showed decreased amounts of storage iron. Total colonoscopy was normal. Upper gastrointestinal endos copy showed a loss of folds in the second part of the duodenum and a biopsy from the second part of duodenum showed intraepithelial lymphocytes, flattening of duodenal mucosa, lymphoplasmacytic infiltration in lamina propria, and crypt hyperplasia (Marsh class 3). Immunoglobulin A (IgA) anti-tissue transglutaminase antibodies (IgA-tTG) was markedly elevated to more than 300 u/ml. Bone mass densitometry revealed osteopenia. He was under observation in short intervals at the Oncology clinic with abnormal finding as hypercellular bone marrow on bone marrow biopsy. Celiac disease diagnosis was made multivitamins, mineral, intravenous iron sucrose complex given at a dose of 100 mg twice weekly. Replacement and gluten free diet replacement treatment was initiated. On day 14th of treatment hemoglobin increase upto 6.1 g/dL , WBC count to 6.4 Ãâ€" 103/mcL, and platelets were 195 Ãâ€" 103/mcL. We present the first case of celiac disease that presented as primary amenorrhea with pancytopeni a. Discussion – A patient came to medicine OPD presenting primary amenorrhea, diminished secondary sexual character, asthenia, history of weight loss and chronic diarrhea. However, celiac disease is also associated with variable systemic manifestations, including metabolic bone disease, diabetes, thyroid dysfunction and lympho-proliferative malignancies [2]. Given the extreme anemia and the marginal thrombocytopenia and leucopenia. In to improve erythropoiesis she was initiated on iron replacement therapy. Initially which led decrease in WBC counts and platelet. Even though iron deficiency is related with a reactive thrombocytosis [13], when the severity of the iron deficiency increases lead to normalization [14,15] and infrequently even decrease in platelet counts [16,17,18]. Still The precise mechanism of this is indistinct. Cause of pancytopenia in our patient may be related to decrease density of bone and increase free radical damage to hemopoetic stem cell in bone marrow. Extremely low levels o f estrogen hormone observed in our patient which is associated with bone demineralization and infertility, poor secondary sexual character in female. Conclusion Undiagnosed celiac disease is a jeopardy of infertility and pancytopenia. Pancytopenia may be due to decrease bone density result of that more exposure bone more ( haemopoetic stem cell) to free radical. Due to lack of proper nutrition, ovarian capsule could not protect newly growing follicle which lead to poorly development of estrogen hormone dependent secondary sexual character. Women seeking medical advice for this meticulous situation should be screened for celiac disease and bone density (DEXA scan). Adoption of a gluten-free diet could have a positive knock on fertility in such kind of patients. It may be a potentially modifiable (and treatable) risk factor. Futher, a large scale study prospectively study for bone density and ovarian capsule composition to evaluate association between celiac disease and infertility in woman, pancytopenia to clarify these hypothesis. References – Sà ¡nchez E, de Palma G, Capilla A, et al. Influence of environmental and genetic factors linked to celiac disease risk on infant gut colonization by Bacteroides species. Applied and Environmental Microbiology. 2011;77(15):5316–5323. 1b. Green PH, Cellier C. Celiac disease. N Engl J Med. 2007;357:1731–1743. Rashtak S, Murray JA. Review article: coeliac disease, new approaches to therapy. Alimentary Pharmacology Therapeutics. 2012;35(7):768–781. Ravikumara M, Tuthill DP, Jenkins HR. The changing clinical presentation of coeliac disease. Archives of Disease in Childhood. 2006;91(12):969–971. Rossi M, Bot A. Celiac disease: progress towards diagnosis and definition of pathogenic mechanisms. International Reviews of Immunology. 2011;30(4):183–184. Aggarwal S, Lebwohl B, Green PHR. Screening for celiac disease in average-risk and high-risk populations. Therapeutic Advances in Gastroenterology. 2012;5(1):37–47. Megiorni F, Pizzuti A. HLA-DQA1 and HLA-DQB1 in Celiac disease predisposition: practical implications of the HLA molecular typing. Journal of Biomedical Science. 2012;19, article 88 Bargetzi MJ, Schà ¶nenberger A, Tichelli A, Fried R, Cathomas G, Signer E, et al. Celiac disease transmitted by allogeneic non-T cell-depleted bone marrow transplantation.Bone Marrow Transplant.1997;20:607–9. Borgaonkar MR, Duggan PR, Adams G. Differing clinical manifestations of celiac disease transmitted by bone marrow transplantation.Dig Dis Sci.2006;51:210–2 Schloesser LL, Kipp MA, Wenzel FJ. Thrombocytosis in iron deficiency anemia.J Lab Clin Med.1965;66:107–114. Dincol K, Aksoy M. On the platelet levels in chronic iron deficiency anemia.Acta Haematol.1969;41:135–143. Choi SI, Simone JV, Jackson CW. Megakaryocytopoiesis in experimental iron deficiency anemia. Blood.1974;43:111–120. Lopas H, Rabiner SF. Thrombocytopenia associated with iron deficiency anemia.Clin Pediatr.1966;5:609–616. doi: 10.1177/000992286600501008. Berger M, Brass LF. Severe thrombocytopenia in iron deficiency anemia.Am J Hematol.1987;24:425–428. doi: 10.1002/ajh.2830240412. Mubarak AA, Awidi A, Rasul KI, Al-Homsi U. Thrombocytopenia responding to red blood cell transfusion.Saudi Med J.2004;25:106–109.

Reaction Paper on the Movie Gi Jane

Msg Marcelito S Adriano 723484 (FA) PA Subject:Reaction Papers on We Were Soldiers As I watched the movie† We Were Soldiers† I recall what is happening in any unit, as the Battalion Commander, Company Commander, Platoon Leaders, Sergeant Major and Troops portray different roles. Leader shows set as an example. He is intelligent, thinking, brave and determined leader. He studies the nature of his enemy carefully. He won’t ask to his man to do, if he can’t do it by himself. He trains his men thoroughly, preparing them for the incoming mission. The Leaders influence the thoughts, attitudes and behaviors of others.It is, therefore, important that their morale is kept high so that they are ready for sacrifice whenever necessity arises. The officers have their own responsibility for commanding the soldiers in combat which is the greatest challenge for each of them even for the risk of their lives. The soldiers shows leadership as they oblige to set one direction f or the rest of them, they help each other what lies ahead, they also help to visualize what they want to achieve, they were encourage and inspire to meet their mission. A responsible family man shows also to this movie.The image of a father which shows closeness to his children, concern for the future of his family and a better husband to his wife. The movie shows an ordinary soldier which other people cannot be seen it. So it is better that the filmmaker produce this kind of movie so that we can give a recognition to our soldier. won't ask man to do what he won't do himself: â€Å"I will be the first to step on the field and I will be the last to step off,† he assures his troops. He reads books and studies the nature of his enemy carefully. He trains his men meticulously, preparing them for the ominous battle to come. Men will die,† he tells his troops, knowing that he and his men are at a disadvantage against an enemy on their own turf. In addition to Gibson, Greg Kin near, Sam Elliot, Barry Pepper, and Keri Russell all give outstanding, A+ performances.Kinnear plays Bruce Crandall, a chopper pilot showing determination and courage while still revealing his fear of death in the course of battle. Pepper plays Joe Galloway, the journalist who rides into the heat of battle to get his story first-hand. (Just wait until you hear his reason for becoming a journalist instead of a soldier. And in spite of my personal disdain for her character on the WB's Felicity, Russell inspires us as a strong-willed mother, in spite of the possibility of losing her husband Jack Geoghegan (Chris Klein) at war. The film does an exceptional job of transitioning from place-to-place, whether from one area of the battlefield to another, to the women and children back home, you always have a good sense of where things are happening and when they're taking place. When one platoon is cut off from the rest of the soldiers, when riverbeds are won and lost, you know exactly what effect it has on the battle.You experience first-hand the grave danger these soldiers experienced. You mourn their deaths and cheer their victories because in spite of the fact that you're sitting in a movie theater, you feel like you're there in battle with them, facing the possibility of death, witnessing the horror of it all. Writer-director Randall Wallace (The Man in the Iron Mask) spends a fair amount of time showing us what is going on behind enemy lines from the point of view of the North Vietnamese. I first heard this was an element of the film before I saw it and was afraid they were going to portray the communist North Vietnamese in a sympathetic light.But, interestingly, these scenes added to the drama and suspense of the film. We see what each leader is thinking and planning for the next attack, which only builds more suspense in anticipation of the next scene to come. A sense of family is well-portrayed among the soldiers, and especially among the wives at home. Madele ine Stowe plays Julie Moore, the wife of Lt. Col. Moore. She heads up the group of wives, giving moral support and preparing them as best she can for the possible death of their husbands. She and Russell show us the chilling events of how they dealt with relaying the notices of the deaths of their friends' husbands.What is lacking in the film is mention of how the war started, or that North Vietnam was communist. Although these are well-known facts, they are too important to pass over in a film about the Vietnam War. The filmmakers have been saying in their media appearances that this is an anti-war movie due to the graphic nature of the battle scenes. Be prepared: the battles scenes are graphic, but I did not come away thinking they were pro- or anti-war. The sheer quantity of gore can never trump the morality of why we fight a war.These scenes only dramatize the risks of fighting a war, and who and what is at stake. The political elements shown in the film (e. g. , how we went int o Vietnam unprepared, and failed to properly arm our men in the best way possible) only demonstrate, in my view, that if we do choose to fight a war, we must do so acknowledging the risks and then proceed with the moral certainty that our cause is right, with only one goal: to win. And Young is a tribute to the nobility of those men under fire, their common acts of uncommon valor, and their loyalty to and love for one another.

Diary extract from the poem blessing Essay

Today was the best day ever; the pipe through our village burst. I first spotted it on the way back from my two mile hike to the well, I had two buckets in my hands had spilt a little water on the way back when seeing a spurt of water coming from the pipe. I filled up the buckets and ran home, I told everyone in the village to bring buckets and cups and everything, by this time the gap had grown and there was a good amount of water coming from it. Everyone gather around bring mugs and tin cans to collect some clean water, we filled our metal bath tub with our buckets and everything we could, we have so much water now, the crops we have tried to grow have been watered and we have kept a good amount to water them more often, the drought had finally ended, there hasn’t been rain in a while, but I believe that this is the work of god, he’s finally come through for us, everyone had prayed and thanked him for this deed, the party still hasn’t finished, I am tired, I have been dancing and singing and drumming until the sun rose again, I was the village’s favourite person today because I spotted the leak that has praised us all, I wouldn’t trade the feeling I had for anything in the world, people chanted my name and cheered all night long I loved it, none of the water is being wasted anything waterproof is being filled with clean healthy water, I will not have to go on my hike for water for the next few days and I will not have to be thirsty we are going to church again tomorrow and I think that the whole village will be there just to thank him for this blessing. I can’t believe how lucky we were, this is truly a miracle, the water came when we needed it the most, when everyone was finding it harder and harder to drink the dirty water, but the question is how long will this water last? How long will it take for the rich people to realise they are paying for our water? And will they stop it? I believe that these questions will be answered in time, God may have let this miracle but I don’t think there is much he could do to change those idiots, they have everything, clean house, clean food and clean drinking water and we have nothing. Our homes are dirty so is our food and out drinking water they just get water whenever they want whereas we have to walk over 2 miles to get dirty water from a well. Everyone hates them if only we could swap places for a week, they would know what it’s like how hard it is for us just to survive, to stay alive but they have no idea I wish something could be done about this.

Marilyn Monroe s Fight Against Mental Disorder - 1468 Words

Marilyn Monroe’s Fight Against a Mental Disorder One of the most famous and iconic women in history, known by the name of Marilyn Monroe, lived a life of a star in the views of thousands of fans. From her beauty to her beautiful, bubbly personality, and the fame she acquired through movies and photographs might be the world to many, but for Marilyn it was worthless. Her exterior expressed happiness and pure bliss in front of the cameras, but nobody seem to pay attention to what was going on in her head much less her mental wellbeing. Her mental problems escalated with time and lead to her untimely death at the age of thirty-six (Bingaman, 2012). The news of her death shocked many, but more over the fact that she killed herself with an overdose (â€Å"A psychological†, 2014). During this time, therapeutic interventions used during her time were ill-conceived and implemented, which in a different setting could have possibly saved her life (Doll, 2007). After her death, in formation about her early life gave a sign that Marilyn Monroe had a predisposition to a mental disorder, which only worsen over time expressed in her inability to have a normal-stable life. Marilyn Monroe was born as Norma Jeane Mortenson on June 1, 1926, by her mother Gladys Pearl Baker (Doll, 2007). Norma Jeane began her life without her father as he disappeared before her birth (Doll, 2007). The unfortunate events of Norma Jeane began when she was placed in a foster home after her mother wasShow MoreRelatedDorothy Dandridge : African American Woman1979 Words   |  8 Pagestime, the early 1930’s through the 1960’s, that was saying something. Racism was a lot worse then what it is now, but it made it harder for African Americans to achieve their goals, especially African American women. Dorothy was very worth looking up to now and when she was alive. 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